Sports Medicine and Neuropsychology

the Neuropsychologist's Role in the Assessment and Management of Sports-related Concussions:a Special Issue of applied Neuropsychology

Eric A. Zillmer

• Publisher: Psychology Press
• Year: 2016
• ISBN:
  9781317708018
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The focus of Sports Medicine and Neuropsychology is the question of what role the neuropsychologist should have in the diagnosis, treatment, and management of sports-related concussions. The goal of this special issue is to examine the most current issues facing this growing and dynamic field of neuropsychology. The first article is dedicated to reviewing current issues in the neuropsychological assessment of concussions in sports-related events. The next paper examines data on over six million practice-and-game-exposures among athletes participating in the NCAA's Injury Surveillance System. Two contributions examine the empirical role that neuropsychologists can have in the area of concussion research. The final two papers review the advantages and limitations on computer-based assessment of sports-related concussions and discuss neuropsychology's role in return-to-play decisions following them.

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ARTICLES

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Current Issues in the Identification, Assessment, and Management of Concussions in Sports-Related Injuries

Catherine K. McKeever

Department of Psychology, Drexel University, Philadelphia, Pennsylvania, USA

Philip Schatz

Department of Psychology, Saint Joseph’s University, Philadelphia, Pennsylvania, USA

The recent literature has focused on the need for appropriate identification, assessment, and management of sports-related concussion. This article addresses current issues in the prevalence and assessment of sports-related concussion. Despite a paucity of research on female athletes and youth athletes, there is evidence that female athletes are at higher risk for injury than males and that concussions may affect children and young adolescents differently than older adolescents and adults. Sideline, baseline, and postconcussion assessments have become prevalent in documenting preinjury and postinjury performance, tracking recovery rates, and assisting return-to-play decisions. New computerized assessment procedures are growing in popularity and use. Future directions in the assessment and management of sports-related concussion include increased research on prevalence rates and effects of concussions for females and youth athletes, educating parents of youth athletes as well as family physicians on the importance of baseline and postconcussion cognitive assessments, and further validation of computerized assessment measures.

Key words: concussion, sports-related injury, mild traumatic brain injury, neuropsychological assessment, athletes, computerized assessment, baseline assessment, sideline assessment

Assessment of sports-related concussion has received considerable attention within the field of neuropsychology over the past decade. Specific research and applications have focused on a mechanism and pathophysiology of injury, the grading of concussions and recovery rates, return-to-play guidelines, and the development and validation of neuropsychological assessment measures. Important issues, such as the scarcity of research on the incidence of concussions in youth and female athletes, and the recent trend toward standardized and computerized assessment measures are, however, not as well represented in the current literature. It is the intention of this article to focus on neuropsychology’s contributing role in the identification, assessment, and management of these emergent issues.

Prevalence of Sports-Related Concussions

Sports-related injuries represent approximately 20% of the estimated 1.54 million head injuries that occur yearly in the United States. Nine percent of all sports injuries are thought to be concussions (Erlanger, Kutner, Barth, & Barnes, 1999), and between 2% and 10% of all athletes are at risk for sustaining a concussion (Ruchinskas, Francis, & Barth, 1997). It is estimated that 10% of all college and 20% of all high school football injuries will be head injuries, which amounts to approximately 250,000 annually. Collins, Grindell, et al. (1999) found that 34% of 393 college football players had sustained at least one concussion and 20% reported a history of two or more concussions while on the team. During the 1997–1998 and 1998–1999 football seasons, 21% of football players were found to have had concussions, the majority of which were mild or Grade 1 according to the American Academy of Neurology (AAN) severity grading guidelines (Kelly & Rosenberg, 1997).

Although concussion in professional and college athletes is widely reported in the literature, concussion in high school athletes has only recently begun to receive similar attention. Powell and Barber-Foss (1999) estimated the number of concussions in high school varsity athletics to be 63,000. During a 3-year time span, 5.5% of all sports-related injuries reported among 235 high schools were concussions. Sports-related head injuries are most likely to occur among adolescents playing football (Baker & Patel, 2000). Powell and Barber-Foss (1999) found that 63.4% of sports-related injuries in high school football were concussions. Other activities in which youth athletes sustain sports-related concussions include wrestling, soccer, basketball, soft-ball, baseball, field hockey, and volleyball.

Incidence of sports-related concussion appears to be increasing as a function of the number of the total sports activities, the number of previous sports years of the youth athlete, the recentness of the study, and the level of athletic participation (e.g., high school vs. college). Barth et al. (1989) reported that 10% of college football players in the Virginia football study sustained concussions each year, and 42% of their sample had sustained at least one previous concussion. Since then, incidence of previous concussion appears to have increased for collegiate athletes. Similarly, high school athletes appear to be sustaining concussions at a greater rate, as compared to collegiate athletes participating in the same sport. For example, concussion rates among college soccer players are estimated to be approximately 1 per 3,000 athletic exposures (AE; Green & Jordan, 1998). In contrast, concussion rates among high school soccer players have been reported to be higher at 1 per 2000 playing hours (Boden, Kirk-endall, & Garrett, 1998). Between 7% and 11% of all sports-related injuries sustained by Canadian amateur hockey players aged 15 to 20 (over the 1998–1999 and 1999–2000 seasons) were concussions; 60% of these reported having sustained at least one concussion during either a game or practice (Goodman, Gaetz, & Meichenbaum, 2001). Moser and Schatz (2002) recently reported that 97% of athletes age 14 to 19 years, sampled from a boarding school with mandatory sports participation requirements and who had participated in numerous sports over a period of many years, had sustained at least one previous sports-related concussion.

Younger athletes appear to be at increased risk for concussions. Giza and Hovda (2001) discussed the potential vulnerability of youth athletes who sustain concussions during critical stages in brain development, especially during a time of increased plasticity. They hypothesize that concussions in the developing brain may ultimately impair this plasticity; however, it is not yet clear whether this impairment is permanent or temporal. It is possible that participants in the initial Virginia football study represented youth athletes from a different culture or with a different history of athletic participation. College athletes from the mid–1980s would have been participating in little league and club sports in the 1970s, whereas high school athletes in the late 1990s were participating in such sports activities in the late 1980s and early 1990s. Although there is no empirical data available on this specific variable, Moser and Schatz’s (2002) sample was comprised of youth athletes with an average of 5 to 7 previous years of participation, as well as current participation in multiple sports. It is unlikely that athletes from the 1980s were being shuttled from soccer to lacrosse to baseball practice by era-equivalent “soccer moms.” Thus, it appears that there may be a higher chance of sustaining concussive injuries when an athlete participates in more sports, has played for a higher number of years, and competes during high school years or earlier.

Additionally, the higher incidence of concussion rates in adolescents may simply be the result of younger, more susceptible brains. Although overall survival from severe head injury may be more likely in the pediatric population than in adults (Tepas, DiScala, Ramenofsky, & Barlow, 1990), traumatic brain injury in children and adolescents can lead to persistent cognitive dysfunction, even when no initial effects are observed (Giza & Hovda, 2001). Increased susceptibility to concussion in children and adolescents, as compared to adults, has been attributed to decreased myelination, a greater head-to-body ratio, and thinner cranial bones, all which provide less protection to the developing cortex.

The number of sports-related concussions appears to be increasing, and they are prevalent in all levels of sports participation. With the pervasive nature of sports-related concussion comes the need for appropriate identification by professionals, such as neuropsychologists, who are trained to investigate such injuries in a systematic and useful manner. Neuropsychologists have a knowledge base, which can contribute to an understanding of the susceptibility of sports-related concussion and different rates of recovery among disparate age groups. Integrating knowledge of the plasticity and repairing mechanisms of the brain, along with a comprehensive understanding of cognitive functions, neuropsychologists can provide unique insight to identifying and managing sports-related injuries in children, adolescents, young adults, and older adults.

Gender Differences

The National Athletic Trainers’ Association study was the first major research effort delineating at-risk concussion differences between male and female athletes (Powell & Barber-Foss, 1999). In this study, female athletes were consistently found to be at higher risk for sustaining concussions than male athletes participating in the same high school sport: 1.14 concussions (per 100 player-seasons) in girls soccer versus .92 in boys soccer, 1.04 in girls basketball versus .75 in boys basketball, and .46 in girls Softball versus .23 in boys baseball. These gender disparities represent approximate female-to-male concussion ratios of 5:4 for soccer, 4:3 for basketball, and 2:1 for softball and baseball. Similarly, Dick (1999) presented data from the National Collegiate Athletic Association (NCAA) Injury Surveillance System in which female athletes were at nearly twice the risk for concussion than male athletes playing soccer (.578 vs. .348 injuries per 1,000 AE) and lacrosse (.618 vs. .334 per 1,000 AE).

These trends do not appear to carry over to all sports or to athletes of all age ranges. Concussion rates in college soccer players (0.31 per 1,000 AE for male athletes and 0.33 per 1,000 AE for female athletes; Green & Jordan, 1998) and basketball players (36.8% of males, 31.3% of females; Echemendia, 1997) were found to be nearly identical for both genders. Barnes et al. (1998), however, observed that 78% of head injuries incurred by female athletes in Olympic soccer matches were the result of a collision with another player, as compared to 65% of head injuries for male athletes. Differences in brain chemistry and other as yet under-investigated neuroanatomical differences may account for this disparity; nevertheless, it is not yet clear why female athletes are at higher risk for sustaining concussions than male athletes.

Contrary to these findings, Boden et al. (1998) postulate that participants in boys soccer tend to represent a higher incidence of head injuries than girls soccer, perhaps due to boys’ greater willingness to engage in risk-taking behaviors. This trend toward increased risk-taking may explain why 89% of male versus 43% of female Olympic soccer players reported a prior history of concussion (Barnes et al. 1998).

Even if female athletes are sustaining concussions at the same rate as male athletes, there is a lack of data, research, and focus on female concussions. Although many research efforts focus on NCAA Division I football, a uniquely male sport, the overwhelming majority of studies representing sports such as soccer, rugby, basketball, and lacrosse are based primarily on male participants. An ideal manner by which to address this need can be met by neuropsychological research, which offers the unique opportunity to investigate the potentially different neuroanatomical and neurochemical elements that contribute to the distinct rates of sports-related concussions sustained by female athletes versus male athletes. Neuropsychological investigation into the possible disparities between female performance and male performance on neuroc...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Introduction
• Articles